Lessons Learned From the Pandemic for Emergency Medicine


By John G. Holstein, Director of Business Development, Zotec Partners

As emergency medicine recovers from the COVID-19 pandemic, the specialty cannot overlook all the changes that occurred over the last two and a half years. What emergency medicine practices can do is move forward with a greater sense of stability about their futures and financial standing with the right processes, protocols, and technological solutions in place.  This article explores four core areas that were impacted during the pandemic, with recommendations for how emergency medicine practices can address the changes in 2022 and beyond. 

Volume Changes 

It is important to assess and evaluate the volume metrics of emergency medicine practices prior to the pandemic. This includes volume statistics as well as the associated staffing and payment parameters that were in place at the time. As the pandemic initially took hold on the U.S., emergency departments began seeing a decline in volume, with some visit volumes declining 40-50-60%, or even higher compared to pre-pandemic levels. The need for analytics, and particularly predictive analytics to swiftly adjust to these visit level changes required access to data 24/7/365. The use of data access and analytics was not solely to adjust staffing of attending emergency physicians and advanced practice providers, but it was also needed to stay financially agile as cash flow monitoring became imperative due to the drastic declines in volume.  

As the pandemic continued, telehealth became the preferred treatment in some emergency departments, but also for the primary care networks and retail healthcare giants who now plunged full-bore into the space. Today virtually every healthcare retail giant, i.e., CVS, Rite-Aid, Walmart and Amazon have made public their intentions of targeting emergency departments’ low acuity patients. Their intent is to suggest this patient category does not need emergency department care. Also notable is the same retail giants are developing programs to care for chronically ill patients. It may behoove emergency medicine practices to evaluate and decide whether they want to retain lower acuity patients, dubbed by some as the “bread-and-butter” of the specialty. Continued slow and/or no response may leave the specialty without some measure of this patient volume as others are moving very quickly to capture them, with enticements centered around care, when and where you want it.  

In a hypothetical analysis of a 120,000-visit emergency department being reimbursed across the board at Medicare rates, if all 99281, 99282 and 25% of 99283 visits were lost, it would cause a $600,00+ financial loss. At a loss of all 99281, 99282 and 50% of 99283 patients, the loss becomes $1.2Mi

Regarding traditional Medicare patients seen in U.S. emergency departments, this author analyzed Medicare data from 2016 through 2020. Summary findings include the following: 

  1. There is an across-the-board, i.e., emergency physicians, physician assistants, and nurse practitioners decline in 99283 Medicare patients.  
  1. Among emergency physicians there is slippage for 99284 patients, with increases in 99284s for both PAs and NPs. 
  1. As per point #2, there is a similar pattern for 99285 patients for all three provider types. 
  1. There is an across-the-board, i.e., emergency physicians, physician assistants and nurse practitioners increase in 99291 patients. 

These findings make it important to carefully monitor both volume and acuity mix shifts, as both shifts have the potential for significantly impacting the finances of our practices.  

Acuity Mix Changes 

As the pandemic evolved and emergency department volumes dropped, acuity levels shifted dramatically toward higher levels of care. Coupling these changes with volume changes posed major challenges for many emergency medicine practices and presented them with the same need of accessing their practice data and analytics 24/7/365. This need remains today as the specialty edges back toward a steady state, leveraging data and associated analytics as core tools for effectively and efficiently managing the practice.           

Payer Mix Changes 

Historically the payer mix of emergency medicine practices has been consistently stable. Additionally, focusing on the self-pay mix these patients have historically been no-pay. The combination of two factors changed both of these scenarios, and the emergence from the pandemic forecasts even more changes to anticipate and prepare for going forward.  

First, the Affordable Care Act initially gave more patients secured insurance coverage than in prior decades. Second, the continuing explosion of patients being insured by high deductible plans has brought about an entirely new image of the self-pay, emergency department patient. Today, self-pay patients covered by high deductible plans are not “no-pay” patients, and, they are paying patients IF they are approached and engaged using technological processes and tools. Patients have become much more sophisticated in how they will engage and what solutions are appropriately presented to them. Finally, monitoring reports that continually inform practice executives about what is working and not working will ensure more patient payments.  

Today’s patients expect an Amazon-type consumer experience, with some preferring traditional paper statements, some text options, some email, some “live” call center options, and others a hybrid of all of these options. Success in engaging these patients requires the technology and reporting of changing patient preferences. Otherwise, there is risk in patients filing complaints to hospital administration for deficient follow up protocols and/or, at minimum, delays in their payments with the associated increase in a practice’s accounts receivable and slowing of cash flow.   

As we emerge from the pandemic, it will be imperative to scrupulously monitor the practice’s payer mix. The door that provided substantial funding through the pandemic is starting to close, which will cause shifts in the practice mix. It is possible that millions of people will lose their coverage, and the transition to getting coverage again may be a lengthy process. These changes in the payer insurance mixes of emergency medicine practices are discussed in many current industry publications.  It will be important to monitor these mixes looking for shifts to and from Medicaid; to and from employer-based insurance coverages and straight shifts to traditional self-pay. The latter shift could become permanent for some patients, while for others, the shift to traditional self-pay may be transitory. As noted above there is also shifting occurring within the traditional Medicare mix of patients. This requires close tracking as patients increasingly consider Medicare Advantage programs. This latter shift additionally requires close attention to potential contracting options for practices.  

These shifts will need to be quickly identified and addressed as the potential for both cash flow and bad debt impacts cannot be missed. Engaging today’s patients “where-they-live” means using the right approaches and techniques that today’s emergency medicine patients are demanding and requiring. It is a very different world today, where respect for patients’ preferred modes of communication and interaction are paramount. Older legacy processes and platforms for patient engagement no longer fit the needs of today’s patients and are too risky for successful emergency medicine practices. 


It is always imperative for emergency medicine practices to be supported by a strong compliance program, and with the increasing incidence of cyber-attacks on hospitals, insurers and physician practices, external certifications are becoming increasingly more important and significant. Revenue cycle management relies on SOC-1, SOC-2, PCI-DSS and HITRUST certifications to support and protect our emergency medicine practices.  

The SOC reference refers to “Service Organization Controls.” The SOC-1 and SOC-2 certifications are issued by the American Institute of Certified Public Accounts. SOC-1 certification involves an outside audit of all core revenue cycle management processes that impact a practice’s financial reporting. SOC-2 certification focuses on the organization’s non-financial reporting controls as they relate to data security, availability, processing integrity, confidentiality, and the privacy of the revenue cycle company’s system. PCI-DSS certification is likewise an outside audit of all processes surrounding credit card processing. HITRUST certification is a third-party certification that represents the “gold standard” of protection today.  These certifications are very well respected by hospital c-suite executives, giving them added assurance and comfort with their emergency medicine practice partners.  

In sum, as the specialty emerges from the pandemic, the lessons learned for emergency medicine practices include being fortified with unlimited data access, on all devices, 24/7/365, inclusive of predictive analytic reporting.  Practices must take care and scrutiny of volume and payer mix shifts that cannot be missed, as well as being bolstered by outside certifications that provide both the practice and its hospital partners with more assurances and security. The industry and entire healthcare landscape is changing very quickly, and the specialty must continue to embrace the challenges and adapt appropriately to the changes.      


  1. HIT Trust Alliance. The Industry-Recognized Gold Standard for Providing the Highest Level of Information Protection and Compliance Assurance.  https://hitrustalliance.net/certification/hitrust-risk-based-2-year-r2-validated-assessment/?gclid=EAIaIQobChMI66zltaeF9wIVxPrICh21RQoTEAAYAiAAEgJtjfD_BwE 
  1. Holstein, John Hypothetical Emergency Department Analysis of Low Acuity Patients. Available upon request 
  1. Holstein, John Medicare Acuity Analysis: 2016-2020. Zotec Partners. Available upon request 
  1. Kaiser Health News. Patients’ Perilous Months-Long Waiting for Medicaid Coverage Is a Sign of What’s to Come: https://khn.org/news/article/patients-perilous-months-long-waiting-for-medicaid-coverage-is-a-sign-of-whats-to-come/ 
  1. Bram Sable-Smith and Rachana Pradhan. Modern Healthcare. April 4, 2022. During the pandemic, the rate of Americans without health insurance dropped to a near-historic low thanks to federal initiatives. But when the public health emergency lapses, that could all change. https://www.modernhealthcare.com/insurance/end-covid-emergency-could-mean-huge-loss-health-insurance  
  1. iv Emerson, Jacob. Becker’s Payer Review. April 7, 2022. Over 3 million could lose health coverage next year if ARP tax credits expire, study finds https://www.beckerspayer.com/payer/over-3-million-could-lose-health-coverage-next-year-if-arp-tax-credits-expire-study-finds.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=3458I2901623G1X 

To view the full July 2022 newsletter click here.